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Kambô Health Check Form

Thank You for your interest in Kambô Ceremonies

In order to book a place at an upcoming group circle or private ceremony, we first have to take you through the consultation process to ensure the medicine is suitable for you.

Please carefully complete the health check form below and we will get back to you as soon as possible. Provided all is ok, we will get you booked in for a ceremony and provide payment details.

It's important that you take the time to complete this form with care and please be honest and clear in your responses. All information is confidential.

Please note, if you have experienced Kambô with us in the last 6 months, you do not need to complete this form again. You may email us directly at [email protected] to book your place on an upcoming ceremony.

Your Information

Contact Details:

Which ceremony would you ideally like to attend? (All 6pm-9pm unless stated otherwise)

Health Questionnaire

What's your date of birth?

Have you received Kambô before?

Have you ever had a serious heart problem?

If yes, please specify:

Have you ever had a stroke?

Are you on any medication for low blood pressure?

Have you ever had a brain haemorrhage?

Have you ever had an aneurism or blood clot?

Do you suffer with serious mental health problems (excluding depression or anxiety)? If yes, please provide more details:

Are you on any medication for anxiety or depression? If yes, please name any medication(s) below:

Have you ever experienced a panic attack?

Have you ever experienced a psychotic episode?

Do you have a family history of mental health illness?

If yes, please provide more details:

Are you undergoing, or have you undergone in the past 6 weeks, chemotherapy or radiotherapy?

Are you taking immune suppressant for organ transplant?

Are you taking other immune suppressants?

Are you taking slimming, serotonin, or sleeping supplements? If yes, please name any medication(s) below:

Are you currently or possibly pregnant?

Are you breast feeding a child?

Do you have Addison's disease?

Do you have Ehlers Danlos Syndrome?

Do you have Epilepsy?

Are you recovering from a major surgical procedure (within 6 weeks)?

Are you under 18 years old?

Have you had a Covid vaccination?

If yes to Covid vaccination, please provide us with the following dates in the box below - date of 1st vaccine, date of 2nd vaccine, & date of booster(s):

Have you received Botox in the last 3 weeks?

Do you have a drug or alcohol addiction?

Are you fasting or water fasting?

Do you have Boerhaave's Syndrome or have you suffered from Spontaneous Rupture of the Oesophagus?

Have you suffered injury or trauma to the Oesophagus/Escophagus from endoscopy?

Have you had a tumour in your throat?

Have you had an ulcer in your throat?

Have you suffered physical trauma or injury to your neck?

Have you had Bulimia?

Do you suffer from Gastro-intestinal Reflux?

Do you have a history of smoking?

Do you suffer from chronic inflammatory response syndrome due to mould exposure?

Do you have untreated eosinophilic esophagitis?

Do you have Diabetes?

If yes to Diabetes, please let us know if you have Type 1 or Type 2?

Do you have a Gastric Band?

Do you have any other conditions or on any other medication we need to know about? If yes, please state below:

Please note that by submitting this form you are agreeing to be contacted by Julia² by email. You will have the option to receive our monthly newsletter and can unsubscribe at any time, but we need to be able to contact you to arrange your Kambô Ceremony.

** We are away from Wednesday 2nd October 2024 and so will be out-of-office for a little while, but we will pick up your form submission when we return to work on Monday 21st October and get back to you ASAP **